New health services needed for rise in 100-year-olds

Over 35,000 people lived to 100 years or more in England over the last ten years, with a large proportion subsequently dying from frailty exacerbated by pneumonia, according to a new study by King's College London. With the number of centenarians set to grow, end-of-life care needs to be tailored to the increasing frailty in this age group, warn the King's palliative care researchers.

Boosting care home capacity and planning health services for the rise in centenarians could help to reduce reliance on hospital admission at the end of life and ensure a better quality of end-of-life.

Centenarians – people aged 100 years or over – are a rapidly growing demographic group worldwide. In 2011, centenarians globally numbered over 300,000. They are projected to reach three million worldwide by 2050, and 17 million at the end of the century. In the UK, this group has steadily increased since 1956 with numbers roughly doubling every 10 years. The latest Office of National Statistics figures indicate that 13,350 centenarians were living in the UK in 2012. Over half a million are expected to be living in the UK by 2066.

Few studies have looked at the health and social care needs of centenarians compared to younger cohorts of older people, or the implications of extreme longevity for health policy and services. The King's study, funded by the National Institute for Health Research Health Services and Delivery Research (HS&DR) Programme, examined the cause and place of death in 35,867 centenarians in England between 2001 and 2010, and compared these findings with those of people who died in their 80s to 90s. The study also looked at factors such as the effect of socioeconomic deprivation on place of death.

The 35,867 people in the study spanned the age range 100-115 years (average age 101), and mainly comprised women (87 per cent) and widowed people (85 per cent). The number of centenarian deaths per year in England increased from 2,800 in 2001 to nearly 4,400 in 2010. Areas of highest deprivation in the UK had the lowest proportion of centenarian deaths, with dying more likely to occur in hospital than in a community setting. The North East of England had the lowest overall proportion of centenarian deaths (4 per cent).

Over the ten-year period, around 60 per cent of centenarians died in a residential or nursing care home, a quarter died in hospital, a tenth died at home and a small number (0.2 per cent) in a hospice.

'Old age' was the most common cause of certifying death (28 per cent), followed by pneumonia (18 per cent) and other respiratory diseases (6 per cent); stroke (10 per cent); heart disease (9 per cent) and other circulatory diseases (10 per cent); dementia and Alzheimer's disease (6 per cent); and cancer (4 per cent). Pneumonia accounted for the largest group of hospital deaths, while across non-hospital settings 'old age' formed the largest category followed by pneumonia. Overall, three-quarters of centenarian death certificates stated 'old age' as either an underlying cause (28 per cent) or contributing cause (47 per cent).

The main causes of death changed with increasing age. In the group aged 80-85 years, heart disease was stated on 19 per cent of death certificates, with 'old age' on only one per cent of certificates.

Catherine Evans, Clinical Lecturer in Palliative Care at the Cicely Saunders Institute, King's College London said: "Centenarians have outlived death from chronic illness, but they are a group living with increasing frailty and vulnerability to pneumonia and other poor health outcomes. We need to plan for health care services that meet the 'hidden needs' of this group, who may decline rapidly if they succumb to an infection or pneumonia. We need to boost high quality care home capacity and responsive primary and community health services to enable people to remain in a comfortable, familiar environment in their last months of life.

"Compared to other European countries the proportion of people aged 90 years and over dying in hospital in England is high, and the number dying in care homes is low. For example, in the Netherlands and Finland more than three-quarters of people aged over 90 die in a long-term care setting such as a nursing home; far fewer die in hospital.

"Hospital admission in the last weeks of life accounts for a third of the total cost of end-of-life care per patient. Increasing the number of care home beds could reduce the reliance on hospital care, but we need to ensure caliber services are provided by GPs, community nurses and other healthcare working with social care providers to enable people to remain in their usual residence at the end of life if they choose."